Assessing Survival and Grading the Severity of Complications ...downloads.hindawi.com/journals/crj/2017/6294895.pdfAssessing Survival and Grading the Severity of Complications in Octogenarians

Research ArticleAssessing Survival and Grading the Severity of Complications inOctogenarians Undergoing Pulmonary Lobectomy

Andrew Feczko,1 Elizabeth McKeown,2 Jennifer L. Wilson,3 Brian E. Louie,1

Ralph W. Aye,1 Jed A. Gorden,1 Eric Vallières,1 and Alexander S. Farivar1

1Division of Thoracic and Foregut Surgery, Swedish Medical Center and Cancer Institute, 1101 Madison Street,Suite 900, Seattle, WA 98104, USA2Surgical Specialists of Charlotte, 2001 Vail Ave., Suite 320, Charlotte, NC 28207, USA3Department of Surgery, Chest Disease Center, Beth Israel Deaconess Medical Center, 185 Pilgrim Road, Suite 201,Boston, MA 02215, USA

Correspondence should be addressed to Andrew Feczko; [email protected]

Received 15 November 2016; Revised 9 January 2017; Accepted 11 January 2017; Published 8 February 2017

Academic Editor: Hisao Imai

Copyright © 2017 Andrew Feczko et al.This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Introduction. Octogenarians are at increased risk for complications after lung resection. With alternatives such as radiation,understanding the risks of surgery and associated survival are valuable. Data grading the severity of complications and long-term survival in this population is lacking. We reviewed our experience with lobectomy in octogenarians, grading complicationsusing a validated thoracic morbidity and mortality schema. Methods. We retrospectively reviewed consecutive patients aged ≥80undergoing lobectomy between 2004 and 2012. Demographics, clinical/pathologic stage, complications, recurrence, and mortalitywere collected. Complications were graded by the Seely thoracic morbidity and mortality model. Results. 45 patients (mean age82.2 years) were analyzed. The majority of patients (28/45, 62%) were clinical stage IA/IB. 62% (28/45) of patients experienced acomplication. Only 15.6% (7/45) were considered significantly morbid (≥ grade IIIB) per the Seely model. Perioperative mortalitywas 2% and half of patients were living at a follow-up of 53 months. Overall five-year survival was 52%. Conclusions. In carefullyselected octogenarians, lobectomy carries a 15.6% rate of significantly morbid complications with encouraging overall survival.These data provide the basis for a more complete discussion with patients regarding lobectomy for lung cancer.

1. Introduction

Due to the high incidence of lung cancer in octogenar-ians, surgeons are increasingly confronted with the clin-ical challenge of how best to treat these patients withresectable lung cancer. Fourteen percent of patients diag-nosed with lung cancer in the United States from 1988–2003were ≥80 years old [1] with the peak incidence occurringbetween ages 75–79 [2]. With the general population livinglonger and the baby boomer generation reaching this agebracket in the next decade, it is imperative that we betterunderstand complications and survival in this growing agegroup.

Making optimal treatment recommendations can be chal-lenging for treating physicians as octogenarians in generalhave more comorbidities and a worse performance status

than the younger population. While the gold standard sur-gical therapy for early stage lung cancer remains anatomicresection [3], physicians may be hesitant to refer thesepatients for surgical evaluation and other treatment optionsincluding stereotactic body radiation therapy (SBRT) andwedge resection may be suggested [4]. Currently, long-termsurvival data for SBRT are limited and show a wide rangeof survival ranging from a 3-year survival of 42% for stageI [5] to 83% for stage IA [6] (see Table 4). In addition, thesurgical literature regarding octogenarians with lung canceris diverse and often includes patients with a wide varietyof clinical stages and resections (i.e., wedge, lobectomy, andpneumonectomy). As a result, broad 5-year survival ratesranging from 18.2% to 69.6% [7–17] have been reportedwhichare likely strongly related to variable inclusion data and extentof resection (see Table 3).

HindawiCanadian Respiratory JournalVolume 2017, Article ID 6294895, 9 pageshttps://doi.org/10.1155/2017/6294895

https://doi.org/10.1155/2017/6294895

2 Canadian Respiratory Journal

Prior publications have documented that octogenariansexperience higher complication rates after lung resectionwhich ranges from 8.4 to 68.8% [7–14, 16–19]. Data regardingthe severity, morbidity, or impact of those complications hasyet to be elucidated using a standardized validated system,leaving physicians with an incomplete understanding ofassessing short-term surgical risks versus long-term benefit.Furthermore, surgeons lack the data that allow them tocharacterize morbidity and complications beyond “major orminor” when counseling their patients. In order to reconcilethis, the Seely morbidity and mortality schema was designedfor application to thoracic surgical patients [20]. It providesa standardized and validated framework for physicians todescribe complications based on the level of interventionrequired [20].

Defining complication severity is important in the over-eighty population to allow for accurate patient counselingregarding surgical outcomes and to guide surgical treatmentalgorithms. We sought to gain further understanding of theinherent morbidity assumed by an octogenarian deemedappropriate for lobectomy and to characterize complicationsbased on a validated thoracic surgery schema. Furthermore,we assessed long-term survival to contextualize more com-pletely short-term risks versus long-term survival.

2. Methods

We performed a single center retrospective review of con-secutive patients aged eighty or greater who underwentlobectomy approached by thoracotomy, video assisted tho-racoscopic surgery (VATS), or robotic assisted methodsbetween 2004 and 2012. All patients were staged accordingto the American Joint Committee on Cancer (AJCC) 7thedition guidelines [21]. The Institutional Review Board (IRB)approved the study and data was entered into a securedatabase. Individual patient consent was waived due to theretrospective nature of the study.

Key data elements included age, gender, body massindex (BMI), comorbidities, percent of predicted forcedexpiratory volume expired in 1 second (FEV1), percent ofpredicted diffusion capacity of carbon dioxide (DLCO),operative approach, conversion of minimally invasive oper-ative approach to thoracotomy, mean operative time, meanestimated blood loss, intraoperativemortality, complications,intensive care unit (ICU) stay, clinical and pathologic stage,procedure performed, hospital length of stay (LOS), posthos-pital patient disposition to home or skilled nursing facility(SNF), follow-up duration, disease recurrence, patient status(living or deceased), and cause of death if applicable.

Patients were staged as follows. Cross sectional imagingwas used to determine tumor size and clinical T stage (cT).Clinical node negative status (cN0) was determined if thepatient had a standardized uptake value (SUV) <1.5 onpositron emission tomography (PET), a biopsy of a PETpositive node that was ultimately pathologically benign, orbiopsy of lymph node(s) > 1 cm in largest diameter that waspathologically benign.

Each attending surgeon determined patient operabil-ity based on the patient’s preoperative imaging, medical

comorbidities, activity tolerance, pulmonary function test-ing, and nutrition status. Specifically, this included patientswith an ECOG score of 0 or 1, a FEV1 and DLCO > 40%predicted after lobectomy, and no anginal symptoms. Patientswith a significant cardiac history or questionable cardiacreserve were referred to their cardiologist or newly evaluatedfor clearance to tolerate a surgery and general anesthetic.Each patient performed an in-office stair walk where heartrate and oxygen saturation were recorded while walking atleast two flights of stairs. Patients who became significantlydyspneic or had an oxygen saturation less than 92% whilewalking two flights were considered inoperable. No comor-bidity precluded consideration for an operation; however,care was taken to optimize these conditions (i.e., bloodglucose and pulmonary function) prior to consideration ofsurgery. This assessment determined the ability of a patientto tolerate general anesthetic and a lobectomy through anymodality. Once operability was determined, the decision toproceed with a thoracotomy or minimally invasive (VATS orrobotic) procedure was at the surgeon’s discretion.

We employed the Seely classification system, whichcharacterizes complication severity based on the need forgeneral anesthesia separating minor from major complica-tions. Grade I complications include any complication notrequiring intervention; grade II complications include anycomplication requiring pharmacologic intervention; gradeIIIA complications include any intervention not requiringgeneral anesthesia. Major complications were defined asgrade IIIB (any complication requiring general anesthesia),grade IV (any complication requiring ICU admission, singleorgan failure, or reintubation), and grade V (complicationsleading to death) (see Table 2).

Clinical follow-up was calculated from the date of dis-charge to the last clinic visit. In cases where a patient waslost to follow-up, status was verified by using the socialsecurity death registry and/or by contacting their primarycare physician. Survival data was analyzed by the Kaplan-Meier method. A univariate analysis was performed to iden-tify factors that influence overall survival including medicalcomorbidities, clinical and pathologic stages, tumor size, andcomplications (all and severe ≥IIIB). Statistical analyses werecompleted using SPSS 18.

3. Results

A total of 45 (male = 23) patients underwent lobectomy.No patients received neoadjuvant therapy prior to resection.Themost common comorbidity was hypertension (56%) (seeTable 1). All patients were high functioning with an ECOG of0 (39/45, 86.7%) and 1 (6/45, 13.3%). The majority of patients(42/45, 93.3%) underwent preoperative cardiac evaluationby a cardiologist. Nearly all patients were clinically stagedwith a diagnostic chest CT and PET. Thirty-nine patients(86.7%) underwent preoperative cervical mediastinoscopy.Clinical staging information was available for 41/45 patients.Of these, 20 were stage IA (51%), 8 stage IB (21%), 5stage IIA (11%), 1 stage IIB (2.2%), and 5 stage IIIA (11%).Two patients underwent lobectomies for metastasectomy,and staging information was unavailable for the remaining

Canadian Respiratory Journal 3

Table 1: Patient demographics.

Mean age (range) 82.2 (80–89)Mean BMI (range) 25 (17–43)Mean FEV1% predicted (range) 86 (43–123)Mean DLCO% predicted (range) 71 (42–110)Tobacco history: 𝑛 (%) 39 (87%)Mean pack years 30Comorbidities: 𝑛 (%)

HTN 25 (56%)CAD 14 (31%)COPD 12 (27%)Prior CT surgery 12 (27%)Atrial fibrillation 10 (22%)Diabetes 3 (7%)Renal disease 1 (2%)Steroid dependent 1 (2%)

BMI: body mass index, FEV1: forced expiratory volume at one second,DLCO: diffusing capacity for lung for carbonmonoxide,HTN: hypertension,CAD: coronary artery disease, CT: cardiothoracic, and COPD: chronicobstructive pulmonary disease.

four patients. All patients undergoing lobectomy for lungcancer were clinically node negative and without evidence ofmetastasis (cN0 and cM0) prior to resection.

Thoracotomy was performed most commonly (27/45,60.0%) followed by VATS (12/45, 26.7%) and robotic assisted(3/45, 6.7%). In two cases (2/15, 13.3%), a minimally invasiveapproach was converted to thoracotomy. Mean operativetime was 228 minutes (range 106–381 minutes) and meanestimated blood loss was 50mL. There was no intraoperativemortality. Disposition data was available for 32/45 patientsand 27/32 (84.4%) were admitted to the ICU postoperatively.The average ICU LOS was 3 days (range 1–13).

The pathology for most patients was non-small-cell lungcancer (NSCLC) (39/45, 86.7%) and the majority of thesewere adenocarcinoma (26/39, 66.7%). Two patients hadmetastatic disease from an extrathoracic source (colorectaland uterine stromal cell carcinoma) and 2 patients had aspindle cell neoplasm (one bronchioloalveolar carcinoma andone neuroendocrine tumor). In keepingwith the early clinicalstage of this population, the most common pathologic stagein the NSCLC patients was IB (13/39, 33.3%). Ten patients(10/39, 25.6%) were IA; 3 patients were IIA (3/39, 7.7%); 3patients were IIB (3/39, 7.7%); 7 patients were IIIA (7/39, 18%);1 patient was IIIB (1/39, 2.6%), and 2 patients were Stage IV(2/39, 5.1%) on final pathology.

Minor complications (grades I–IIIA) occurred in 46.7%(21/45) of patients. New onset atrial fibrillation requiringmedical therapy was the most common complication (22.2%,10/45). Ten patients (22.2%) had a prolonged air leak or fluidcollection that necessitated chest tube for > 5 days. Nine ofthese air leaks resolved while the patient was in hospital, but1 patient was discharged home with a chest tube due to apersistent leak. Four patients (8.9%)were discharged from thehospital with supplemental oxygen therapy per nasal cannula.

Severe postoperative complications (≥IIIB) occurred in15.6% (7/45) of patients. Three patients (6.7%) developed

pneumonia requiring ICU care. Two patients (4.4%) requiredreturn to the operating room for control of postoperativehemorrhage within twenty-four hours of the initial opera-tion. Additional severe complications included myocardialinfarction (2/45, 4.4%) and one inpatient sustained an anklefracture due to a fall, which subsequently required operativefixation (see Table 2). Furthermore, 1 patient (2.2%) withsteroid-dependent COPD died in the perioperative periodon postoperative day 13 due to sepsis induced multiple organsystem failure.

Over half of the patients had a postoperative complicationof some sort (28/45, 62%). Additional complications not cap-tured in the Seely classification system included unexpectedtransfers to the ICU for cardiac monitoring due to atrialfibrillation which occurred in 3/45 (6.7%). Thirty-six of the45 patients had disposition data available. Of these patients,88.9% (32/36) were able to be discharged home and 11.1%(4/36) were discharged to a skilled nursing facility.

During the mean follow-up period of 53 months (range1 week to 84 months), 13.3% (6/45) had disease recurrenceat a mean of 25 months from their operation (4 months–84months) and 51.1% (23/45) died. Causes of death includedlung cancer recurrence in 43.5% (10/23), multiorgan systemfailure in the perioperative period, stroke, amiodarone tox-icity, and sepsis (1 each). Nine patients died of unknowncauses.Mean 5-year overall survival calculated by theKaplan-Meier method was 52%. Medical comorbidities, clinicalstage, tumor size, any complication (grades I–V), and severecomplications (≥IIB) did not significantly influence survivalon univariate analysis.

4. Discussion

While anatomic lung resection remains the standard of carefor the treatment of NSCLC [3], octogenarians are lesslikely to be offered a lobectomy than younger patients. ASurveillance, Epidemiology and End Results (SEER) databasereview of 45,912 of patients aged ≥80 demonstrated thatoctogenarians were twice as likely to receive no local tumorspecific therapy (radiation or surgery) when compared toyounger patients despite a comparable rate of early stagecancers in both groups [1]. This was even significant whencomparing octogenarians to patients aged 70–79 (47%offeredno radiation or surgery versus 28%) [1]. Another studydemonstrated the same trend and showed that as ageincreases, patients undergo anatomic resection less often thanthe general population and are offered radiation therapymoreoften than surgery [22] despite the fact that radiation therapyor nonanatomic lung resection remains second line therapyfor patients with operable NSCLC [3].

Even with improvement in radiation methods fromexternal beam radiation therapy, stereotactic body radiation(SBRT), or stereotactic ablative radiation therapy (SABR)[23], resection offers the best chance for local control [24].In studies including octogenarians who are surgically ormedically inoperable, treatment decisions are a bit easier forhealthcare providers. This study sought to understand andclarify the risks and outcomes of the gold standard therapy(resection) within this group.


Table 2: Complications categorized by the Seely thoracic morbidity and mortality classification system.

Grade Patients𝑛/45 (%)∗ Definition of complication Complication description

(𝑛/48, %)∗∗

I 2 (4.4%) Complication that does notrequire any intervention

Asymptomatic vocal cordparalysis (1, 2.1%), urinaryretention (1, 2.1%), ileus (2,

4.2%)

II 10 (22.2%)Pharmacologic therapy or

minor interventionrequired

Atrial fibrillation (14,29.2%, with 10 being newonset; 10/48, 20.8%∗∗∗),esophagitis (2, 4.2%), newhome O2 (4, 8.3%), seriouselectrolyte disturbance (1,2.1%), acute kidney injury(1, 2.1%), chyle leak (1, 2.1%)

IIIA 9 (20%) Interventions not requiringgeneral anesthesia

Home with chest tube (1,2.1%) stroke (1, 2.1%),bleeding not requiringtransfusion (1, 2.1%),development of a PTXrequiring drainage (1,

2.1%), chest tube duration >5 days (10, 20.8%)

IIIB 3 (6.7%) Interventions requiringgeneral anesthesia

Return to OR:postoperative hemorrhage(2, 4.2%), fracture fixation

after fall (1, 2.1%)

IV 3 (6.7%)

Complication requiringICU support, reintubation,single or multisystem organ

failure

MI (2, 4.2%), pneumonia(4, 8.3%), respiratory

failure (1, 2.1%)

V 1 (2.2%) Any complication leadingto death Multiorgan failure (1, 2.1%)

∗Several patients had more than 1 complication and are listed in the category corresponding to the complication with the highest Seely grade.∗∗Complications are listed individually in this column and many include multiple complications in the same patient(s).∗∗∗The four patients with preexisting atrial fibrillation were not included in the complication rate.O2: oxygen, OR: operating room, and MI: myocardial infarction.

There has been a broad attempt across the surgicalliterature to classify complications by severity in order tostandardize complication reporting. The National CancerInstitute Common Terminology Criteria for Adverse Events(CTCAE) is a system which grades adverse events acrossmultiple diverse areas of medical care on a 1–5 scale [25]. Thevalidated Clavien-Dindo complication classification schemewas created for application to general surgery patients andis graded based upon the level of intervention required totreat the complication, a more practical system than simplyseparating events into major and minor categories [19].Seely et al. published a validated extension of the Clavien-Dindo system for application to the thoracic surgery patientpopulation [20]. Like the CTCAE, complications are gradedfrom I to V based on the level of intervention required totreat the complication, with minor complications consideredgrades I-II and major complications that result in significantmorbidity listed as grades III–V [20]. We used Seely gradein order to provide us with a specific understanding of thepractical morbidity faced by octogenarian population whenundergoing lung resection.

Lower % predicted FEV1 [19], thoracotomy as approach[9, 19], resection greater than wedge [19, 26], and medi-astinal lymph node dissection [11, 16] are associated withhigher complication rates in octogenarians undergoing lungresection. In addition, Port et al. demonstrated a statisticallysignificant shorter length of stay and less ICU admission rateswith VATS over thoracotomy in octogenarians undergoinglobectomy [9]. While we did not seek to find differencesin operative approach in this study, we did not observea difference in complication rates between thoracotomy,VATS, and robotic, likely due to the study size. Minimallyinvasive approaches to lung resection have been shown to beassociated with fewer complications by many authors [9, 19]and should be considered for octogenarians if appropriate.

Long-term survival after lobectomy in the elderly pop-ulation is an important consideration. The calculated 5-year overall survival of 52% in our series was comparableto previous reported 5-year overall survival of 18.2–69.6%[7–17]. Furthermore, for stage IA patients the calculated 5-year overall survival rate was excellent at 78% comparedto 69.6% reported previously [9]. Univariate analysis in our


Table3:Lu

ngresectionin

octogenaria

ns:com

parativ

edata.

Author

Yearso

fenrollm

ent

𝑁Ap

proach

(T,

V,R)

Resection(s)

inclu

ded

(W,S,L,B

,P)

Age

Clinicalsta

ges

inclu

ded

Pathologic

stage

Com

plication

rate(%

overall),

severe

Predictorsof

increased

complications

(𝑝values)

30-day

perio

perativ

emortaiity(%

)

5-year

survival

Predictorsof

poor

survival

(𝑝value)

Portetal.

[9]

1998–200

9121

V=40

T=81

L≥80

(median82)

—I6

5.3%

II25.0%

III10.0%

53.7%,28.9%

severe

requ

iring

significant

interventio

n

Thoracotom

y(63%

)versus

VATS

(35%

)𝑝=

0.00

4

1.7%

56.6%

Bysta

ge:

I=69.6%

II=35.6%

III=

18.2%

Pathologic

stage

Ibor

greater(𝑝=

0.050)

Hanagiri

etal.[18]

1992–1995

18T

S,L,W

≥80

(mean,

82.1)

IA6

IB6

IIB1

IIIA

5

IA4

IB5

IIB4

IIIA

1IIIB

4

50%

—0%

——

Aokietal.

[7]

1981–1998

35—

Wor

S10

L25

≥80

(mean81.2)

IA14

IB10

IIA0

IIB5

IIIA

5IIIB

1

—60%

—0%

39.8%

—

Pagn

iet

al.[8]

1980–1995

54T

W3

S3

L43 B2

P1

chestw

all1

sleeve1

≥80

I II IIIA

—42%,11%

—3.7%

43%

>sta

geI(𝑝

valuen

otgiven)

Clavienet

al.[19]

2000–200

9191

V77%

T

W77

S13

L96 P3

≥80

(median82)

—

I56%

II10%

III9

%IV

3%

46%

Resectiongreater

than

wedge

(𝑝=0.00

64),

thoracotom

yas

approach

(𝑝=

0.034),%

predictedFE

V1

fore

a10%

decrem

ent(𝑝=

0.01)

3.6%

3-year

stage

I(109

patie

nts)

56%

—

Umezuet

al.[10]

2001–2008

44≥80

(mean

82)

65.9%

2.3%

54.5%

Okada

etal.[17]

44≥80

(mean

81.8)

20%

044

.9%

Okamiet

al.[11]

1999

367

—W

80S42

L245

80–9

0(m

ean

82)

II3

00II44

III2

38.4%

Com

orbidityand

mediastinal

lymph

node

dissectio

n

1.4%

56.1%

Advanced

pathologic

stage

and

comorbidity

Chidae

tal.[16]

1981–200

648

—S3

L45 P2

≥80

(mean

81.7)

I36

II3

III9

I30

II8

III10

68.8%

MediastinalL

Ndissectio

n(𝑝

=0.00

4)—

35%

Med

LNdissectio

n(𝑝

=0.022)


Table3:Con

tinued.

Author

Yearso

fenrollm

ent

𝑁Ap

proach

(T,

V,R)

Resection(s)

inclu

ded

(W,S,L,B

,P)

Age

Clinicalsta

ges

inclu

ded

Pathologic

stage

Com

plication

rate(%

overall),

severe

Predictorsof

increased

complications

(𝑝values)

30-day

perio

perativ

emortaiity(%

)

5-year

survival

Predictorsof

poor

survival

(𝑝value)

Suem

itsu

etal.[15]

1981–200

6146

—

W38

(26%

)S17

(11.6

%)

L79

(54.1%

)B7(4.8%)

P1(0.7%

)Ex

plorations

4(2.7%)

≥80

(mean

82.6)

I109

(74.7%

)II14

(9.6%)

III2

2(15.1%

)IV

1(0.7%

)

I94(64.3%

)II16

(11.0

%)

III3

1(21.2%)

IV5(3.5%)

——

—46

.8%

—

Mun

and

Kohn

o[14

]1999–200

655

V

W10

(18.2%

)S7(12.7%

)L37

(67.3

%)

B1(1.8

%)

80–89(m

ean

82.7)

IA32

IB23

I44

II6

III5

25.6%

—3.6%

65.9%

—

Ikedae

tal.[13]

1981–2002

73VandT

L45

(62%

)B2(2.7%)

S6(8.2%)

W20

(27%

)

80–89(m

ean

83)

I60

II10

IIIA

3

I55(74.3%

)II8(11%

)IIIA

5(6.8%)

IIIB

4(5.5%)

IV1(1.4

%)

37%

—4.1%

47%

Pathologic

stage

III

comparedto

II(𝑝

=0.02)

Matsuoka

etal.[12]

1997–200

440

85%

Muscle

sparing

PLT/VA

TS,

15%

stand

ardPL

T

W30%

S30%

L40

%80–89

—

IA52.5%

iB35.5%

IIA0

IIB7.5

%IIIA

5%

20%

—0%

56.9%

—

Current

Stud

y2004

–2012

45T59%

V26%

R26%

L≥80

(mean

82)

IA51%

IB21%

IIA11%

IIB2.2%

IIIA

11%

IA26%

IB33%

IIA8%

IIB8%

IIIA

18%

IIIB

3%IV

5%

62%,17%

—2%

52%

—


Table4:SB

RT:com

parativ

eData.

Author

Yearso

fenrollm

ent

TotalG

y(fr

actio

ns)𝑁

Age

(median)

Clinicalsta

ges

inclu

ded

Follo

w-up

(medianmon

ths)

Com

plications

(NCI

-CTC

grade)

3-year

prim

ary

tumor

control

rate

3-year

localand

region

alcontrol

3-year

rateof

dissem

inated

failu

reDFS

Overall

Survival

Predictorsof

poor

survival(𝑝

value)

Nagatae

tal.[6]

1998–200

448

(4)

4551–87

StageI:

T1N0M

0T2

N0M

030

4%(2)

——

—3year

IA72%

IB71%

3year

IA83%

IB72%

—

Dales

etal.[28]

2006–200

954

(3)

5548–89(72)

StageI:

T1N0M

0T2

N0M

034.4

12.7%

(3)

3.6%

(4)

97.6%

87.2%

22.1%

3year

48.3%

3year

55.8%

(median

48.1mo)

—

Matsuoetal.[24]

1999–2005

48(4)

6667–86(76.5)

StageI:

T1aN

0M0

T1bN

0M0

T2aN

0M0

35.9

——

——

5year

33.8%

5year

44.6%

(median

35.9mo)

—

Fakiris

etal.[5]

—60–6

6(3)

70T1N0M

0T2

N0M

050.2

8.6%

(3)

1.4%

(4)

7.1%

(5)

88.1%

——

—

3year

42.7%

(median

32.4mo)

—

Timmerman

etal.[29]

2004

–2007

48(4)

6550–9

1(m

edian89)

T1N0M

045.4

9.2%

(3)

——

——

3year7

6%—

Nagatae

tal.[30]

1999–2007

—875

75–9

7StageI:

T1N0M

0T2

N0M

0—

——

——

——

—

Palm

aetal.[31]

1995–200

4100–

141

Gy

8774

StageI:

T1N0M

0T2

N0M

055

1.1%

——

——

5yr

72%

(S1a),62%

(S1b)

—

CurrentStudy

2004

–2012

—45

≥80

(mean

82)

Stages

I–IIIA

5362%

overall,

severe

17%

Seely

grade≥

IIIB

——

——

5year

52%

—


study failed to reveal predictors of better survival aside fromlower pathologic stage. In this study, there was no statisticallysignificant survival benefit dependent on operative approach.

We have observed that many of our patients are con-cerned with the possible need for a nursing facility (SNF) staypostoperatively. For patients in whom disposition data wereavailable (36/45), 32 (88.9%) were able to be discharged homewith 4 (11.1%) requiring discharge to a SNF. These rates aresimilar to other studies which report that 6% [19] and 16.5%[9] of octogenarians require SNF after lung resection.

Limitations to this retrospective review include patientselection bias, lack of a control group, small size, andvariability of operative approach.The classification of compli-cations as minor or major depending on level of interventionrequired does not reflect patient quality of life and the per-ceived invasiveness of the intervention. Additionally, theseresults may not be reproduced at other centers with differentpatient selection criteria and experience. Our follow-up wasalso limited at 1.7 years.

In today’s society, where an 80 year old male can expectto live an additional 8 years (an 80-year-old female canlive another 9.3 years) [27], carefully selected medicallyfit patients over 80 should be offered anatomic resec-tion for early stage, operable NSCLC as per the NCCNguideline recommendations [3]. We found that employingan intervention-based, validated complication classificationscheme is helpful when discussing expected surgical out-comes within this population (octogenarians) and acrossstudies.

We have also shown that appropriately chosen octoge-narians can undergo lobectomy with encouraging overallsurvival. These data should help physicians and surgeonsunderstand the short-term risks and long-term survivalassociated with lobectomy, provide a framework for futurecomparison to SBRT or wedge resection, and allow surgeonsto counsel older patients more thoroughly.

In conclusion, while 62% of octogenarians undergoinglobectomy had a complication, severe complications usingthe Seely morbidity and mortality complication schemaoccurred in only 15.6% of our study group. In addition, octo-genarians deemed operable by a thoracic surgeon, regardlessof stage or surgical approach, can achieve a reasonable 5-yearsurvival of greater than 50%. Using this data as a foundation,providers can accurately counsel similar patients regardingtheir surgical complication risk and expected survival.

Disclosure

This data was published as a preliminary abstract in theJournal of Thoracic Oncology, “Session PL03: PresidentialSymposium including Top Rated Abstracts” Nov 2013; 8(11)S2-1348.The authors had full control of the production of thismanuscript.

Competing Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper.

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